A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
Rapid pulse.
Decreased B/P.
Pallor.
Flushed Face.
Correct Answer : A,B,C
Choice A rationale
Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body’s tissues.
Choice B rationale
Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale
Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale
A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1170 "]
Explanation
Step 1 is to convert all fluid intake to mL.
Using the conversion factor 1 oz = 30 mL7 and 1 cup
= 240 mL8, we get: 1 cup of coffee = 240 mL 4 oz of orange juice = 4 × 30 mL = 120 mL 3 oz of water = 3 × 30 mL = 90 mL 1 cup of flavored gelatin = 240 mL 1 cup of tea = 240 mL 5 oz of broth = 5 × 30 mL = 150 mL 3 oz of water = 3 × 30 mL = 90 mL Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL So, the nurse should record a fluid intake of 1170 mL.
Correct Answer is B
Explanation
Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
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